Erectile dysfunction (ED or impotence) is the inability to get or maintain an erection that allows sexual activity with penetration. Unfortunately ED is relatively common and affects up to 50% of men aged 40 to 70 years. It is worth noting that ED is not a disease, but generally a symptom of some other problem, be it physical, psychological or a mixture of both. You shouldn’t worry about an occasional failure
to get or keep an erection as this is generally normal and may be related to drinking too much alcohol, anxiety and tiredness. In cases where it is ongoing the cause should be investigated by your Doctor.

There are many possible causes and equally many treatments that your Doctor can prescribe to meet your needs including oral medications (usually tablets, lozenges or liquids), vacuum erection devices, injections directly into the penis, gels for intraurethral injection, penile prosthetic implants and counselling. There are many causes of ED. It was thought that ED was mainly caused by psychological factors, such as anxiety or depression. In reality only 1 in 10 patients suffer ED as a result of psychological factors.

The majority of ED cases are related to something physical or anatomical, illness (such as diabetes, high blood pressure, high cholesterol, MS and other conditions which affect the nerves), post surgery (lower abdominal such as prostatectomy, gastro-intestinal or radiation treatment), medication related (of which there are many) or lifestyle related (smoking, alcohol consumption, being overweight). ED
generally develops over a period of months or years and results in a gradual loss of function.

It is also worth noting that a man’s sexual drive or performance can be affected by stress. Stress from problems at work, relationship difficulties or financial worries, feeling depressed and anxiety about poor sexual performance can be involved in a failed erection; this then become a vicious circle and can result in ongoing erection issues. This is where counselling can be very effective.

With respect to treatments there are many options available. These include:

• Review of, and where needed, changes to your prescription medications if they are identified as a possible cause (antidepressants, antipsychotic medications, blood pressure medications and medications for BPH are often culprits). The pharmacists at Men’s Health Downunder are able to review your medications to help identify possible culprits
• Psychotherapy and counselling
• Oral medication including Viagra, Cialis and Levitra - these are proprietary products and are generally available at all pharmacies. They are very effective but do have some specific side effects and instructions for their optimal use - particularly around onset of action and if they should be taken with or without food
• Sub-buccal medications are something that we are seeing grow in popularity - these are very similar to the oral medications listed above but tend to work more effectively. They are specially compounded by Men’s Health Downunder on your Doctor’s prescription and allow greater customisation. Your Doctor can sign up to Men’s Health Downunder to access our list of commonly prescribed lozenge formulations and to get further clinical information and support
• Vacuum erection devices - are drug free and tend to create a reasonable erection adequate for penetration. For men who can not take oral medications these devices are a good option and work by increasing blood flow to the penis
• Injections directly into the penis such as Caverject Impulse (intracavernosal injections) - these are very effective even for men who have suffered significant damage to the nerves involved in getting an erection
• Penile prosthetic implants which are more invasive and done after consultation with a Urologist.

It is important that the first approach is to treat the underlying cause of ED if one has been identified. Where an underlying cause can not be identified or the cause can not be resolved, generally the oral or sub-buccal treatments are used to promote a better/stronger erection either with or without a vacuum erection pump.

Oral and Lozenge Medication Overview

Oral medications, otherwise known as PDE5i (phosphodiesterase type 5 inhibitors), are the mainstay of erectile dysfunction treatment and management. They are relatively effective, convenient, side effects are not common and they are accessible with a prescription from your doctor. There are 3 propitiatory PDE5i available in Australia; these include brands such as Cialis (tadalafil), Viagra (sildenafil) and Levitra (vardenafil). Lozenges containing PDE5i are used sub-buccally, meaning that they are placed between the teeth and the cheek and gentle sucked on until they dissolve. These are less commonly seen in Australia as most Doctors are unfamiliar with them despite their advantages over the propitiatory oral tablets listed above. Lozenges are custom made for each individual according to their Doctor’s prescription. This is done to achieve the best possible outcome for patients. Further, it allows a more tailored approach to be utilised. There are a number of benefits to using PDE5i in the sub-buccal form and these will be explored below. As a note, formulas and suggested combinations and dosages have been
compiled by Men’s Health Downunder over many years and are available to Doctors through the Doctor login section of this website.

The main benefit of the sub-buccal lozenges include:

• They allow your Doctor to prescribe a customised option, that being multiple types of ED medications in one lozenge
• Use of the sub-buccal route of administration avoids hepatic metabolism. All PDE5i are extensively broken down by the liver, reducing their effectiveness when taken orally. This is avoided with lozenges, giving greater results
• The onset of action is faster meaning greater ability to have spontaneous sexual relationships

How do they work?

PDE5i inhibitors help the body's natural response to sexual stimulation. They block an enzyme that breaks down the chemical messenger responsible for creating an erection - cyclic GMP (cyclic GMP is created from GMP when nitric oxide in the blood enters the smooth muscle of the penis and this is what causes an erection) - hence cyclic GMP stays in the smooth muscle for longer, which means more erection. So really, these PDE5i do not cause erections, but they help the body's
normal response to sexual stimulation, assisting in the formation of an erection.

As a rule this group of medications is generally used ‘on demand’ and work quite well. For patients post prostate surgery they tend to be quite ineffective as their blood flow and nerve connections have been interrupted. This is why we generally use the injectable PDE5i contained in medications like Caverject and Trimix to give an erection as they do not rely on blood flow alone to elicit their effect.

PDE5i in prostatectomy patients

In patients post prostatectomy we use oral PDE5i inhibitors at low doses to increase blood flow to the penis. This will not likely result in an erection as the doses used tend to be lower than that of the ‘on demand’ doses used to aid sexual function. The other benefit of low dose PDE5i is that they will assist in keeping the blood vessel lining (the endothelial lining) healthy which is vital in getting oxygen from the
blood into the penis tissue keeping it alive and functional. Generally a small dose of Viagra (sildenafil) or Cialis (tadalafil) might be used - 25mg Viagra or 5mg Cialis. The main benefit of tadalafil in this situation over sildenafil (or Levitra - vardenafil)
is that it remains in the blood longer, having an effect for more than 24 hours, where the others are only effective for 4-8 hours. This is important because we want to infer the aforementioned benefits for the penis 24 hours a day to get the maximum benefit. The drawback of tadalafil is its cost compared to sildenafil and this may need to be taken into consideration.

Side effects

Common side effects include facial flushing and a blocked or runny nose. They can also cause headaches, muscle aches and pains, and indigestion. Most side-effects are not troublesome and only last an hour or so. In the case of taking low dose tadalafil every day post prostatectomy, muscular ache (back, neck or thight most commonly) is the most commonly seen side effect and it is seen in approximately 1% of the population. There are many ways to work around these side effects so
please don’t hesitate to contact us if you need assistance in this regard.

When not to take PDE5i

PDE5i are not to be used with ‘nitrate' drugs. These ‘nitrate’ drugs treat certain forms of heart disease - if you are not sure check with your Doctor or Pharmacist. Further, PDE5i should not be used if you suffer from unstable heart disease, which should again be checked and discussed with your Doctor or Cardiologist.

Intracavernosal (penile) injections overview

Your Urologist or Doctor may prescribe erection drugs which are injected into the penis. These are known as an intracavernosal injection. These medications are often used to bypass the oral route of administration. This can be for a number of reasons such as side effects of oral medications, poor outcome of oral equivalents, drug interactions, impaired blood flow and so on. Despite the fact that injections can be uncomfortable (and certainly unnatural for most patients) they are very effective and with the correct dose and technique will be reliable.

The 2 most commonly used medications for penile injection are Caverject (alprostadil) and Trimix, a mixture of 3 ingredients: alprostadil (PDE5i), phentolamine (alpha blocker), and papaverine (vasodilator). These ingredients work by relaxing the smooth muscle and opening the blood vessels in your penis, thus leading to an erection.

Caverject is a propitiatory injection made by Pfizer which is available at most pharmacies (some may need to order it for you). Trixmix comes in a range of strengths and is specially compounded by a sterile compounding Pharmacy. Because each batch is made to your specific prescription, Trimix needs to be specially ordered each time you need it. Men’s Health Downunder Pharmacists can
arrange this for you - please get in touch and we will be happy to arrange it for you and teach you how to use it safely and effectively.

Your Urologist/Doctor will decide which medication and dose is most appropriate for you and provide you with a prescription.

Storing your medication

The alprostadil in Trimix can weaken over time, so Trimix should be stored in the refrigerator and away from light. This will keep the medication stable for a few additional months. If you’re using Caverject the unused syringes can simply be kept at room temperature.

If you have been prescribed Bimix or papaverine alone, you can keep these medication vials at room temperature as they do not
contain the light and temperature sensitive alprostadil.

Intracavernosal injections are generally reserved for patients who do not achieve the desired results with an oral or subbuccal PDE5i (e.g. Viagra or Cialis). These medications are injected into the cavernosal tissue of the penis and work quickly and reliably to give a good firm erection within 10-15 minutes. The main concern expressed by patients prescribed these injections is, not surprisingly, the idea of injecting into their penis. The information below may help to demystify the concept of intracavernosal injection. Men’s Health Downunder is here to assist you with any questions you have so don’t hesitate to contact us if you need support.

There are 2 main intracavernosal injections we use: Caverject (which is available on prescription from most pharmacies) and Trimix (which is specially compounded in accordance with your Doctor’s prescription). There are many formulations/strengths of Trimix and again, as with subbuccal lozenges, these formulas can be accessed by your Doctor in the practitioner section of our website. Generally, intracavernosal injections contain a PDE5i - most commonly alprostadil. You may use these injections up to twice a week (you should not use 2 injections within 3 days - and not more than 8 times in a month)

The goal is to induce an erection lasting 30-60 minutes; this can require some dose adjustment. Your Pharmacist or Doctor can advise on dose adjustment to ensure that you are able to find the best dose for you.

The erection should not last more than two hours, however if it does this is not cause for alarm, it's just not desirable from a patient point of view. An erection lasting more than 3-4 hours is known as Priapism. If this happens you should seek help as detailed in the ‘Priapism fact sheet’ below. Priapism can damage the penis and must be dealt with as soon as possible.

If the penis starts to bend/change shape it may be a side effect of the injections. If this does happen stop using the intracavernosal injections and seek advice from your Urologist/Doctor/Pharmacist. This is known as Peyronie’s disease and again is not desirable and needs to be managed by a healthcare professional. If you have Peyronie’s disease you should not use intracavernosal injections.

Incorrect technique may result in a partial erection or no erection. This does not cause any harm. You can try again on a different day if this occurs and if you are unsure if your technique is correct check with your Pharmacist or Doctor. Inappropriate technique is the greatest cause of a failed injection and is easily corrected with a little bit of help from your Pharmacist. Men’s Health Downunder pharmacists are all specially trained to assist you with your injection technique. Contact us if you need any assistance.

When using intracavernosal injections it is always wise to avoid alcohol as alcohol may counteract their effects, resulting in no, or only a limited, unsatisfactory response. Alcohol may have this effect with any medication used for erectile dysfunction (tablets or injections) and as a general rule should be avoided.

To achieve the best response, you should be relaxed, sexually aroused (either from contact with a partner or from self-stimulation) and not overly tired; this is easier said than done so try your best.

The erection can be uncomfortable and should this occur simple analgesics are recommended e.g. Panadol. for more information see the ‘Priapism fact sheet.'

If you find the injection painful, application of a local anaesthetic cream may be appropriate; we would typically recommend Emla or Numbit 5% which should be applied an hour before and covered with a little spot bandaid - ask us for further advice.

Finally some patients prefer to use a device called Inject Ease or Autoject to assist them with injection of Trimix. This is not appropriate for use with Caverject. Your Men’s Health Downunder Pharmacist can supply you with, and explain how to use the Inject Ease or Autoject device.

The below instructions are to assist patients or their carers to administer an intracavernosal injection.

Do not use the medication if it has particles visible in it or it is cloudy. Do not use if the rubber stopper comes off of the vial

Preparing the Injection

1. Prepare a clean surface for your supplies.
2. Gather your supplies including: medication vial, syringe (single use only), alcohol wipes, sharps container
3. In the case of Caverject Impusle follow the instructions or video given to you
4. Wash your hands well with soap and water

Drawing Up the Medication From the Vial

1. Open an alcohol wipe and wipe the rubber stopper on the top of the vial. You must always wipe the rubber stopper with alcohol before you insert the needle. This will kill any bacteria on the rubber stopper
2. Take out the syringe and remove the cap from the needle. Be very careful not to let anything touch the needle. If anything touches the needle, you must throw the entire syringe away into the sharps container and use a new one as it will no longer be sterile
3. Holding the syringe upright so the needle faces the sky, pull the plunger of the syringe back past the dose you are going to inject. Next, push the plunger back up until the top of the plunger (the thin black line closest to the needle) is at the dose you are going to inject
4. Turn the syringe downward so the needle is facing the floor. Hold the syringe in your hand like you would hold a pen or dart. Hold the syringe close to the needle with your thumb, index (first) and middle (second) fingers. This will keep the needle from bending as you insert it into the rubber stopper. Support the medication vial with your other hand
5. Holding the vial upright and the syringe downward, insert the needle through the circle in the centre of the rubber stopper. Push the plunger down to inject the air into the vial (see Figure 1). This is done because the vial is pressurised. You must replace the amount of medication you remove from the vial with air
6. Turn the vial and syringe upside down (see Figure 2). Hold the syringe with your dominant hand and the vial with your other hand. Don’t let go of the vial, or the needle will bend. Make sure the tip of the needle is in the medication. Rotate the syringe so you’re looking at the numbers and lines on the syringe